Discharge Planner

Job Description

Job Description

Thrive Rehab of Pearland redefines transitional care as the first facility of it’s kind. We combine a progressive model of healthcare with an atmosphere of hospitality and the amenities of a fine luxury resort, designed for guests who require short-term medical therapy or treatment after a hospital stay.  As a company local to Houston, we are seeking a candidate will a helpful attitude and friendly demeanor. 

We are currently looking for a FT Discharge Planner with excellent customer service - energetic, friendly and caring - to provide our guests with compassionate and personal treatment. 

Position Overview

Thrive Rehabilitation of Pearland is seeking a dedicated and compassionate Discharge Planner to join our interdisciplinary care team. In this role, you will be responsible for coordinating safe, smooth, and effective transitions of care for our residents returning to the community, assisted living facilities, or other post-acute care settings.

The ideal candidate possesses strong clinical assessment skills, deep knowledge of community healthcare resources, and a passion for advocating for seniors and their families.

Key Responsibilities

• Care Coordination & Transition Planning: Evaluate residents upon admission to assess post-discharge needs, establish individualized discharge plans, and facilitate safe transitions to home, home health agencies, assisted living, or hospice.

• Interdisciplinary Collaboration: Work closely with physicians, physical/occupational/speech therapists, nursing staff, and insurance case managers to track patient progress and set realistic discharge timelines.

• Resource Facilitation: Arrange post-discharge support services, including Durable Medical Equipment (DME), home health care, transportation, medication delivery, and outpatient therapy.

• Family & Patient Advocacy: Lead discharge planning conferences with residents and their families to address care options, financial resources, and support systems; serve as the primary point of contact for transition inquiries.

• Regulatory Compliance & Documentation: Complete required Social Services assessments and discharge paperwork in compliance with state/federal guidelines, Medicare/Medicaid requirements, and facility policies.

• Insurance & Authorization: Coordinate with insurance payors to secure authorizations for post-discharge equipment, home care visits, or alternative care placements.

Qualifications & Requirements

• Education: Bachelor’s Degree in Social Work (BSW), Nursing (BSN/RN), Healthcare Administration, or a related field in Human Services is preferred.

• Experience: Minimum of 1–2 years of experience in discharge planning, case management, or social work within a skilled nursing facility (SNF), hospital, or long-term care setting.

• Knowledge Base: Strong understanding of Medicare, Medicaid, managed care plans, and local community resources for seniors.

• Skills: Excellent verbal and written communication, strong crisis-intervention skills, high empathy, and proficiency with Electronic Health Record (EHR) systems (e.g. PointClickCare).

Preferred Qualifications

• Licensed Social Worker (LSW/LCSW) or Registered Nurse (RN) license in Texas is preferred.

• Certified Case Manager (CCM) or Certified Discharge Planner (ACDP) designation.

• Bilingual capabilities in English and Spanish are preferred.